Our Lady of Angels Fire – Chicago

December 1, 2015

On December 1, 1958, a fire broke out in the basement of Our Lady of the Angels Catholic School in Chicago, IL. 1,600 kindergarten to eighth grade students attended the school. Originally built in 1910, the school was remodeled and additions were added several times over the years. The school was provided with one fire escape and fire extinguishers. There were no fire sprinkers, no automatic fire alarms, and no connection to the fire department. The stair towers were not fire resistant and there were no fire doors for heat or smoke separation to help separate the two floors of the school. Construction of the building was wood with brick exterior walls. As was customary for the time, the wood floors were coated with flammable solvent based wax.

December 1, 1958 was a cold day. Sometime between 1400 and 1420 hours, a fire started in a cardboard trash barrel. The fire burned undetected for an estimated 15 to 30 minutes before a window shattered, allowing fresh oxygen to feed the flames. Smoke was filling the building and the fresh supply of oxygen caused the fire to flash up the stairwell. A pipe chase which ran from the basement to the cockloft became an express route for flames to reach the attic. Flames swept through the hallways before the teachers and students on the second floor realized there was a fire in the building. The only way out was the fire and smoke filled central hallway. 329 students and 5 nuns were trapped on the second floor. Their options were to wait for the fire department to arrive, or jump out the windows into the crushed rock 25 feet below. Some of the nuns brought the children together in the classrooms to pray to God for the fire department to arrive in time to save them. Some prayed. Some children jumped. Other children were pushed or fell out the windows.

The firemen arrived within four minutes from being called, but not in time to save many of the children or nuns. The witnessed the unforgettable outcome of the fire. Children were killed in their fall to the ground. Smaller children could not climb over the window sills, and died in the classrooms. Firefighters witnessed the children in the classrooms when the fire flashed over inside the rooms, killing all the souls remaining inside the room.

A calamity of errors plagued the event. The fire burned without being discovered for approximately one half hour. The fire department was originally given the address of the Rectory which was located around the corner from the school. Valuable minutes were lost because engines needed to relocate and hose lines had to be dragged to the school. The gate to the courtyard of the school was locked, preventing firefighters from getting to the children along the south classroom windows.    160 children were rescued from the school, but 87 children and three nuns lost their lives.

The school passed a fire department inspection two weeks earlier. Because the school was built prior to the 1949 Chicago Fire Code for Schools, it was “grandfathered” into the old code and safety improvements were not required to be made.

As a result of the fire and horrendous loss of life, fire codes nationwide were changed to require schools to upgrade their fire safety programs and devices to meet current fire codes. Another sad lesson as to how the fire codes are written in calamity, blood, and loss of life…

Potential Fire Protection Failures – ASSE Philadelphia Chapter – April 16, 2015

April 7, 2015
Why did this sprinkler head fail to operate in a fire?

Why did this sprinkler head fail to operate in a fire?

I will be presenting, “Potential Fire Protection Failures” at the Philadelphia Chapter of American Society of Safety Engineers’ luncheon meeting on April 16, 2015 at the Parx Casino East (Philadelphia Park Racetrack Building), 2999 Street Road, Bensalem, PA.

The pictured sprinkler head was in an actual fire. Unfortunately, it failed to operate. Why did this sprinkler head fail? What could have been done differently? How could an effective Inspection, Testing, and Maintenance program have prevented this failure?

Fire protection systems have a stellar performance record. Fire sprinklers are effective in 97% of fires in which they operate. What causes failure in the other 3%? See some of the factors which can compromise fire protection systems. The main focus of the topic is to show various parts of a fire protection system and explain why and how they may impact the proper operation of the system. The issues identified in the presentation are typically found in many industries and can be applied to the self inspection program at any facility. The talk will include examples of fire protection items which may be compromised. These items could be detected and identified by a well organized fire protection self inspection program.

On April 16 I will describe the events leading up to the fire this sprinkler head was to have controlled, why it the sprinkler head failed to operate, and the aftermath of the fire. I think you will be interested in what happened.

Additional details may be found at phila.asse.org.

I hope to see you there.

Implementing a Fire Protection Inspection, Testing, & Maintenance Program for Water-Based Fire Protection Equipment

March 4, 2015

Beattie Fire Protection & Risk Consulting, LLC is proud to announce the publication of a new article in the March 2015 edition of Occupational Health & Safety, Vol. 84, No. 3 (www.ohsonline.com). The article, “Implementing a Fire Protection Inspection, Testing, & Maintenance Program for Water-Based Fire Protection Equipment”, was selected as the featured article on the cover. The article discusses issues in implementing an ITM program for water-based fire protection systems covered under NFPA 25. A copy of the article is also posted at https://waltbeattie.com/articles-by-walt/ .

Katie Jane Memorial Home for the Aged – 72 died

February 17, 2015

The Katie Jane Memorial Home for the Aged located in Warrenton, MO was the location of a fire which killed 72 people, almost half of the residents, on February 17, 1957. The two-and-a-half story facility was located approximately sixty miles west of St. Louis, and housed 155 elderly people. It had been converted to a nursing home two years earlier after serving as the site for Central Wesleyan College.

The fire began at approximately 2:40 p.m. in a linen closet on the first floor. At the time, a Sunday afternoon religious service was being led by Lutheran minister Walter Schwane, who was leading a hymn, “What a Friend We Have in Jesus.” A scream was heard from one of the visitors who had noticed smoke near her uncle’s room. Soon, she saw intense flames near the closet and screamed “Fire!” as she alerted everyone throughout the facility.

Within 30 minutes, the annex building became an inferno. Local residents attempted to rescue residents, however, the building’s roof eventually caved in It is reported that the flames and smoke were visible from 30 miles away.

A state official had inspected the facility just one week before the fire. After the fire, it was learned that the sister of the Nursing Home’s manager had operated a similar facility in Hillsboro, MO. That facility caught fire in 1952 and 18 people died in the fire.

The fire cause was not determined. It was later learned that the operator was operating without a valid license, was not provided with automatic sprinkler systems, had inadequate fire escapes, no alarm system, and no evacuation plan. Some residents were locked in their rooms, which was a common practice in many homes during that period.

In March, 1957, Missouri governor James T. Blair signed a bill establishing minimum safety standards for nursing homes in the state of Missouri.

Do you have a loved one in a nursing home or assisted living facility? If so, have you checked out the safety features of the facility? Fire is a grave concern for such facilities because many times, the occupants are not able to exit on their own. They may have physical or mental issues which may prevent them from evacuating in a safe manner. There may be limited staff on duty, especially over the nighttime hours.

Some items to note when selecting a care facility include:

  • Is the building well maintained? Is the construction substantial and is each wing separated by fire walls and fire door assemblies – or at least smoke separation walls and door assemblies? When was the building constructed or last renovated and to what year’s code? An old building built to 1950’s codes and grandfathered from updates may not be the level of safety you want for your loved ones.
  • Are multi-story facilities provided vertical fire cut-offs of substantial fire rated construction. Are the stair towers clearly marked?
  • Is the housekeeping maintained in an orderly fashion? Make sure exit routes are not cluttered and every door is clear of obstructions.
  • Is the facility equipped with fire sprinklers, fire detection systems, automatic closing doors?
  • What is the occupant to staff ratio, especially at night on weekends, and on holidays? Are there enough staff on hand to effect an orderly evacuation?
  • Is smoking allowed? If so, what safeguards are in place to supervise smoking activity and ensure smoking controls?
  • Are evacuation routes and procedures posted? Are all exits clearly marked? Are drills carried out in a serious manner and supervised by a qualified employee or third party? If a “Defend In Place” emergency response is implemented, was the building built to facilitate this response concept? Has the staff been fully trained in “Defend In Place” procedures and understand the boundaries of each fire compartment?

Talk to the administrators and supervisors about fire safety. Your questions should be addressed thoroughly and completely.

Talk to your loved one about fire safety, what they can do to protect themselves in the event of a fire. Talk to them about closing their door at night to help prevent smoke from entering their room if a fire starts.

For more information, a good publication is U.S. Fire Administration/National Fire Data Center, “Fire and the Older Adult”, FA-300/January 2006. It may be downloaded at: www.usfa.fema.gov/downloads/pdf/publications/fa-300.pdf . Also, NFPA and many other governmental agencies publish information easily downloadable on the internet. Please take the time to research fire safety for your elder loved ones.

Fire Sprinkler Systems: Ensuring Reliability Through Inspection, Testing, & Maintenance

October 2, 2014


OSH Supercast

A webinar presentation with Occupational Health & Safety

Your facilities have fire protection and sprinkler equipment installed, but are you sure that they are providing reliable and adequate protection at this very moment? Have the sprinkler systems installed in your facilities lulled you into a false sense of security? Are you doing what is needed to properly inspect, test, and maintain your water based fire protection systems? Are your sprinkler systems ready for response to fire? Are your fire pumps exercised and flow tested as required? Are trip test and internal inspection frequencies of your equipment adequate? Are your records reflecting the service they represent? Do you have hidden impairments in your fire systems?

Please join Walt on October 2, 2014 at 11:00am ET – 10:00am CT – 8:00am PT when he will review the requirements of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Knowing the minimum requirements will help enable you to verify and evaluate the service being performed on your water based fire protection systems.

DATE: October 2, 2014

TIME 11:00AM ET – 10:00AM CT – 8:00AM PT

Register here or go to:


Fire Evacuation: Developing Situational Awareness

September 23, 2014

Fire Alarm Pull Station

The fire alarm sounds! What do I do? Well, first of all, it depends on where I am when the alarm sounds. If I am in a hotel and the alarm sounds in the middle of the night, my job is to evacuate via one of the routes I have previously scoped out. Every time I check into a hotel room, I scope out the evacuation routes. Yes, I am one of those guys who will ask the front desk associate where the stairs exit and I will many times walk the stairs to see exactly where they exit. If you have never done this, try it sometime. You may be surprised the response the front desk agent associate offers – and where you end up after walking the stairs, especially in an old hotel. In one hotel attended for a group meeting, a group of us walked the stairs and found ourselves in the basement, adjacent to the door of the main kitchen, and nowhere near an outside exit. The building was built prior to current-day life safety codes and is grandfathered in by the municipality. The lesson – don’t be surprised by the unexpected.

How about a theater or restaurant? I hope you scope out the exits when you go in – I do. So do many of my friends. It seems safety professionals and firefighters do this automatically – not a conscious effort, but a conditioned response to entering new surroundings. It is maintaining situational awareness. Emergency responders learn to do a quick size-up when entering a situation, and this provides a basis for future plan of action in the event of an emergency. The clues and cues noted during the initial size-up will help if an emergency does arise.

Based upon the initial size-up, clues, and cues, the experienced person will subconsciously anticipate what might happen in the next few minutes, hour, or next “period” of time. This level of situational awareness takes a long time to achieve – years of experience and repetitive assessments.

Many people do have such a sense of situational awareness in some areas of their life, but perhaps not other areas. For example, a new teenage automobile driver does not have the same situational awareness on the road as their parents, and must learn through experience and (hopefully) continued driver safety awareness and education. Auto insurance companies recognize this and respond with increased premiums for those under 25 years of age. To compound this lack of situational awareness, a newly licensed teen driver may not even realize or accept their lack of competence. They are not yet able to anticipate actions, reactions, and situations to which they may be forced to respond within the next few seconds. After a few close calls, a few surprising incidents, a few minor fender benders, they reach a realization that they have more to learn. This level of consciousness is the next step in becoming a good driver who can anticipate possible actions of others on the road. Eventually, after several years of practice, a level of unconscious situational awareness developes, and we can drive as if we are in “auto-pilot” mode. This is a state where we absorb clues and cues, process the information, and respond without so much as a conscious thought. Such as hitting brakes and swerving to avoid a collision.

This same development of situational awareness can also be applied to how we respond to a fire emergency. Transferring this situational awareness to a fire condition is not as easy as one might think. Most people do not respond to fires on a daily basis. Most people think they know what to do and will do the right thing in a fire emergency. Unfortunately, we do not always understand our shortcomings. Our lack of practice, knowledge, and awareness may lead to disastrous consequences.

Our place of business – where we work – where we spend almost a quarter of our working life, should be familiar territory. We enter our workplace as a matter of habit. Taking the same elevator to and from our floor, entering and leaving through the same doorway, taking lunch at the same cafeteria, and following the same route. We can become numb to our surroundings. We can go into “auto-pilot” mode. The “auto-pilot” mode should not be relied upon during an emergency. Our normal exit may be blocked and we may need to escape though an alternate exit at the other end of the building. If we do not possess a situational awareness of our surroundings, we may become confused, lost, and unaware of the appropriate response or action.

As managers and safety professionals, we must ensure that every employee is trained and educated in the proper course of action to take in the event of an emergency. The size of your workplace, the hazardous operations conducted, and hazardous materials handled should be part of your employee training. Every employee should understand the hazards which may create an emergency and know what actions they should take in the event an emergency arises. Every employee should understand the function and elements of your emergency action plan. They should understand the hazards, potential emergencies, emergency shutdown procedures, procedures for reporting an emergency, and activating the alarm system. Hazard communication is very important to educate employees in hazards, flammable liquids, toxic chemicals, radioactive sources, or other special hazards.

Evacuation plans should be practiced regularly. I prefer more than annual drills. A year is a long time to wait between training sessions. Training and educational sessions should be provided for all new employees; whenever an employee changes job tasks or departments; when to process changes or new hazards are introduced; when there is a change which alters the floor plan or evacuation routes; when the emergency response plan changes; and whenever management deems the time is appropriate to conduct an unscheduled drill. Encourage employees to develop a situational awareness mentality. Every employee should take a few seconds before every task to review and evaluate the hazards and anticipate undesired outcomes. After a while, every employee will begin to develop a situational awareness for their work tasks and work sites.

Emergencies happen. It is my opinion that every manager and every employee are responsible for the proper actions and response to prevent a catastrophe. Developing a comprehensive emergency action plan that deals with all types of issues specific to a work site is not difficult, expensive, or burdensome. Management and employees should come together to help safeguard each others’ safety and well being. Evacuation is only one part of an effective emergency response program.

CSB Warning Against Use of Methanol During Laboratory and Classroom Combustion Demonstrations

September 15, 2014
 View of "fire tornado" demonstration - Photo CSB

View of “fire tornado” demonstration – Photo CSB

On September 3, 2014, another tragic accident during a science demonstration. A flash fire injured nine people – eight of them children – who were viewing a science demonstration. They were transported to the hospital for evaluation of burn injuries, and one child with more serious burns was admitted to the hospital for treatment.

Concerns have also been raised by other entities, such as the Committee on Chemical Safety of the American Chemical Society (ACS). There is a general call for schools and teachers to immediately end all “rainbow” demonstrations involving methanol or other flammable solvents on open benches. Using flammable liquids in improperly controlled situations may lead to catastrophic results. ACS safety experts advise, “The ‘Rainbow’ demonstration performed on an open bench using a flammable solvent is a high risk operation.” There are well-known safer alternatives to the rainbow demonstration where no methanol is used, only wooden sticks soaked in chemical salts dissolved in water.

You may view a compelling video ” After the Rainbow” at http://www.csb.gov/videos/after-the-rainbow/

Are these demonstrations being conducted in your local schools and museums?

Statement of CSB Chairperson Rafael Moure-Eraso Warning Against Use of Methanol During Laboratory and Classroom Combustion Demonstrations, in the Wake of Reno, Nevada, Museum Fire can be found at http://www.csb.gov/statement-of-csb-chairperson-rafael-moure-eraso-warning-against-use-of-methanol-during-laboratory-and-classroom-combustion-demonstrations-in-the-wake-of-reno-nevada-museum-fire/